securing the future of smaller hospitals - Irish Medical Organisation
securing the future of smaller hospitals - Irish Medical Organisation
securing the future of smaller hospitals - Irish Medical Organisation
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SECURING THE FUTURE OF SMALLER<br />
HOSPITALS:<br />
A FRAMEWORK FOR DEVELOPMENT
Securing <strong>the</strong> Future <strong>of</strong> Smaller Hospitals:<br />
A Framework for Development<br />
Introduction<br />
The <strong>future</strong> organisation <strong>of</strong> our acute <strong>hospitals</strong> is a major policy issue for <strong>the</strong><br />
Government. It is very important that all <strong>hospitals</strong> provide care in <strong>the</strong> right way, at<br />
<strong>the</strong> right location, and in a manner that ensures a safe, high quality service for all.<br />
People have a right to know what to expect from <strong>the</strong>ir acute hospital services,<br />
including what services <strong>the</strong>y will provide. There has been much public debate about<br />
<strong>the</strong> <strong>future</strong> <strong>of</strong> a number <strong>of</strong> <strong>hospitals</strong>, particularly <strong>the</strong> <strong>smaller</strong> ones, and some<br />
uncertainty about what will happen to <strong>the</strong>m in <strong>the</strong> months and years ahead.<br />
The Government is publishing this Framework now to <strong>of</strong>fer clear information about<br />
<strong>the</strong> role <strong>of</strong> our <strong>smaller</strong> <strong>hospitals</strong> and what <strong>the</strong>y will do in <strong>the</strong> <strong>future</strong>. It is an initial<br />
blueprint, setting out <strong>the</strong> main service changes that we see happening over <strong>the</strong><br />
coming years. We will build upon <strong>the</strong> framework as our consultation process<br />
continues and as we make fur<strong>the</strong>r more detailed decisions on individual changes.<br />
- The <strong>future</strong> <strong>of</strong> <strong>smaller</strong> <strong>hospitals</strong> is safe<br />
It is important to say that <strong>the</strong> Government is committed to <strong>securing</strong> and fur<strong>the</strong>r<br />
developing <strong>the</strong> role <strong>of</strong> our <strong>smaller</strong> <strong>hospitals</strong>. No acute hospital will close. We<br />
believe that <strong>the</strong>re is a strong role for <strong>smaller</strong> <strong>hospitals</strong>, in which <strong>the</strong>y will provide<br />
more services, not fewer. The challenge is to make sure that <strong>the</strong>y provide <strong>the</strong> right<br />
type <strong>of</strong> services, which can safely be delivered in <strong>the</strong>se settings, so that we maximise<br />
<strong>the</strong> benefit to patients.<br />
All <strong>hospitals</strong>, irrespective <strong>of</strong> size, as well as associated GP and community services,<br />
must work toge<strong>the</strong>r in an integrated way. Co-operative working is key to success,<br />
and <strong>hospitals</strong> in each area will need to work all <strong>the</strong> more closely to meet <strong>the</strong> needs <strong>of</strong><br />
patients. This must happen nationwide and within regions with:<br />
• improved speedier communications (to be certain everyone clearly understands<br />
<strong>the</strong>ir own and each o<strong>the</strong>r’s roles and how <strong>the</strong>y interact);<br />
• better emergency patient transport and improved access to diagnostic services<br />
including direct access for GPs to key diagnostic services<br />
• improved staff flexibility (with more rotation between <strong>hospitals</strong> <strong>of</strong> key staff to<br />
allow staff to gain more experience and to provide more services locally in<br />
<strong>smaller</strong> <strong>hospitals</strong>).<br />
- Programme for Government<br />
Under <strong>the</strong> Programme for Government 2011-2016, we are committed to developing a<br />
universal, single-tier health service, which guarantees access to medical care based<br />
on need, not income. The Government will introduce a system <strong>of</strong> Universal Health<br />
Insurance which will end <strong>the</strong> present unfair two-tier service. A key part <strong>of</strong> <strong>the</strong> new<br />
system will be to develop independent not-for-pr<strong>of</strong>it hospital trusts in which all<br />
<strong>hospitals</strong> will function as part <strong>of</strong> an integrated group. Already, <strong>the</strong> Minister for Health<br />
has announced his intention to establish hospital groups as a first step towards<br />
hospital trusts. Each Group will have a management team headed by a Group Chief<br />
Executive, with responsibility for performance and outcomes, operating within clearly<br />
defined budgets and employment limits.
Ano<strong>the</strong>r key element is <strong>the</strong> Special Delivery Unit set up by <strong>the</strong> Minister to address<br />
unacceptable waiting times for services in acute <strong>hospitals</strong>.<br />
We do not believe that <strong>the</strong>re can or should be a master blueprint for acute hospital<br />
services which is drawn up centrally and delivered locally. In addition to <strong>the</strong> critical<br />
need for consultation, any such approach would stifle local innovation. Clearly, <strong>the</strong><br />
best solutions will vary between regions; <strong>the</strong>re can be no question <strong>of</strong> a ‘one size fits<br />
all’ approach.<br />
We believe that <strong>the</strong> best way forward will be for <strong>smaller</strong> <strong>hospitals</strong> to operate initially<br />
within Hospital Groups and ultimately within <strong>the</strong> proposed new system <strong>of</strong><br />
independent hospital trusts. This will be a locally effective way <strong>of</strong> ensuring that<br />
<strong>hospitals</strong> deliver on <strong>the</strong> access requirements set by <strong>the</strong> Special Delivery Unit, within<br />
<strong>the</strong> budgets set by Government and <strong>the</strong> safety and quality requirements set by<br />
Health Information Quality Authority<br />
- The Framework<br />
There is much work to be done on organising our acute hospital services<br />
appropriately, to ensure that <strong>the</strong>y are safe, <strong>of</strong> high quality and efficient. In this<br />
Framework we focus in particular on <strong>the</strong> role <strong>of</strong> nine <strong>smaller</strong> <strong>hospitals</strong> which have<br />
been <strong>the</strong> subject <strong>of</strong> particular attention from <strong>the</strong> HIQA:<br />
• Dublin North East:<br />
o Our Lady’s Hospital Navan<br />
o Louth County Hospital Dundalk<br />
• Dublin Mid Leinster:<br />
o St. Colmcille’s Loughlinstown<br />
• South:<br />
o Mallow<br />
o Bantry<br />
• West:<br />
o Ennis<br />
o Nenagh<br />
o St. John’s Limerick<br />
o Roscommon County Hospital<br />
Developing our Smaller Hospitals: Key issues<br />
- Safety<br />
Our first and over-riding concern is <strong>the</strong> safety <strong>of</strong> patients. Much <strong>of</strong> <strong>the</strong> recent debate<br />
about <strong>the</strong> <strong>future</strong> role <strong>of</strong> <strong>smaller</strong> <strong>hospitals</strong> has been prompted by <strong>the</strong> need to deliver<br />
safe services and to address potentially unsafe situations wherever <strong>the</strong>y arise. As<br />
<strong>the</strong> independent statutory agency, HIQA has made important recommendations in<br />
this regard, and we are committed to implementing <strong>the</strong>m. This is about providing safe<br />
services to patients, not about cutting services to save money.<br />
We recognise that <strong>the</strong> safety debate is not confined to <strong>smaller</strong> <strong>hospitals</strong>. It is not just<br />
a question <strong>of</strong> dealing with <strong>smaller</strong> <strong>hospitals</strong>, nor do we assume that larger <strong>hospitals</strong><br />
are by definition safer. We need to look carefully at acute <strong>hospitals</strong> <strong>of</strong> all sizes to<br />
ensure that <strong>the</strong>y meet <strong>the</strong> requirements <strong>of</strong> good practice and patient safety. This will<br />
be helped by <strong>the</strong> ongoing work <strong>of</strong> HIQA including <strong>the</strong> National Standards for Safer,<br />
Better Health Care launched recently, and by <strong>the</strong> plans to introduce a licensing<br />
system for all acute <strong>hospitals</strong> under <strong>the</strong> independent direction <strong>of</strong> a new Patient Safety<br />
Authority.<br />
2
In its reports on hospital safety, HIQA has pointed in particular to <strong>the</strong> type <strong>of</strong> patient<br />
who can safely be treated in different <strong>hospitals</strong>, depending on <strong>the</strong> staffing and<br />
facilities available and <strong>the</strong> volumes <strong>of</strong> patients seen. Because <strong>of</strong> <strong>the</strong>ir size, <strong>smaller</strong><br />
<strong>hospitals</strong> can expect to treat only small numbers <strong>of</strong> patients with certain complex or<br />
acutely life-threatening conditions (e.g. cancer surgery, serious trauma, heart attack,<br />
stroke).<br />
This means that clinical staff do not treat certain conditions frequently enough to<br />
ensure that <strong>the</strong>y can maintain <strong>the</strong>ir skill levels. These small number <strong>of</strong> patients may<br />
also require specialised resources and facilities (e.g. advanced life-support<br />
machines, complex surgical facilities), which it may not be feasible to provide in many<br />
small <strong>hospitals</strong>. The result is that for certain conditions, small <strong>hospitals</strong> cannot<br />
ensure <strong>the</strong> best care. Therefore, patients need to be need to be directed to follow<br />
<strong>the</strong> care pathway appropriate to <strong>the</strong>ir needs.<br />
However, we recognise that where it is necessary to transfer <strong>the</strong> more complex<br />
services from <strong>smaller</strong> to larger <strong>hospitals</strong>, <strong>the</strong> transition must be managed safely and<br />
carefully. It would be counter-productive, for example, to move services from a<br />
<strong>smaller</strong> hospital before <strong>the</strong> receiving hospital was in a position to take <strong>the</strong>m. In some<br />
cases we need interim measures to mitigate <strong>the</strong> risk while services remain at a<br />
<strong>smaller</strong> hospital, while planning an orderly transfer <strong>of</strong> services to a larger hospital<br />
over a period <strong>of</strong> time. In o<strong>the</strong>r cases, it has already been necessary to change<br />
services immediately in response to concerns about patient safety.<br />
- Quality<br />
In addition to delivering safe services, we want to improve <strong>the</strong> quality <strong>of</strong> service. The<br />
key drivers <strong>of</strong> quality will be:<br />
• <strong>the</strong> HSE clinical programmes which plan a structured approach to channelling<br />
patients to <strong>the</strong> right setting and type <strong>of</strong> treatment. They are designed to improve<br />
quality across all <strong>hospitals</strong>;<br />
• <strong>the</strong> National Standards for Safer, Better Health Care;<br />
• <strong>the</strong> HIQA Ennis Mallow recommendations on <strong>the</strong> provision <strong>of</strong> services in acute<br />
<strong>hospitals</strong>; and<br />
• <strong>the</strong> Programme for Government policy on acute hospital services, including <strong>the</strong><br />
move to Hospital Groups and <strong>the</strong>n to independent hospital trusts, licensed by a<br />
Patient Safety Authority and <strong>the</strong> ultimate goal <strong>of</strong> a UHI health system.<br />
The overarching aims <strong>of</strong> <strong>the</strong> clinical programmes are to ensure that all patients will<br />
experience safe, quality care at <strong>the</strong> appropriate time in <strong>the</strong> appropriate environments.<br />
This will require care from a senior medical doctor working within a dedicated<br />
multidisciplinary team, improved communication and privacy for <strong>the</strong> patient.<br />
The HSE clinical programmes provide a clear delineation <strong>of</strong> hospital services based<br />
upon <strong>the</strong> safe provision <strong>of</strong> patient care within <strong>the</strong> constraints <strong>of</strong> available facilities,<br />
staff provision, resources and local factors. Under this framework we are placing <strong>the</strong><br />
<strong>future</strong> growth in healthcare firmly in local (small) <strong>hospitals</strong> which will provide<br />
ambulatory care (including chronic disease management and day surgery),<br />
diagnostics and rehabilitation, with close links to primary health care, for <strong>the</strong>ir local<br />
population.<br />
The Special Delivery Unit’s initiatives to improve <strong>the</strong> performance <strong>of</strong> emergency<br />
departments, in-patient, day case and out-patient services and diagnostics will be<br />
aligned with <strong>the</strong> role <strong>of</strong> <strong>smaller</strong> <strong>hospitals</strong> as set out in this Framework.<br />
3
- Access<br />
It is clear from <strong>the</strong> work <strong>of</strong> <strong>the</strong> Special Delivery Unit that <strong>smaller</strong> <strong>hospitals</strong> can help<br />
deliver faster access for patients by increasing <strong>the</strong> volume <strong>of</strong> elective services <strong>the</strong>y<br />
provide in selected specialties. This will be an important element in <strong>the</strong> drive to<br />
reduce waiting times for patients. In turn, larger <strong>hospitals</strong> will need to recognise and<br />
utilise <strong>the</strong>se services <strong>of</strong>fered by <strong>smaller</strong> <strong>hospitals</strong>, so that <strong>the</strong>y can meet <strong>the</strong> access<br />
requirements for <strong>the</strong> more complex care that only <strong>the</strong>y can provide.<br />
- Developing <strong>the</strong> role <strong>of</strong> <strong>smaller</strong> <strong>hospitals</strong><br />
We can and will expand <strong>the</strong> services delivered in <strong>smaller</strong> <strong>hospitals</strong>, especially in<br />
services such as :<br />
• day surgery (e.g. cataracts, hernia repairs, gynaecological procedures, and o<strong>the</strong>r<br />
surgeries that can safely be done in a day-based environment)<br />
• ambulatory care (including chronic disease management and assessment for<br />
older persons)<br />
• medical services (including cardiac failure clinics, cardiac rehabilitation, COPD<br />
outreach and clinics, rheumatology, dermatology, diabetic day centre,<br />
rehabilitation, and a range <strong>of</strong> o<strong>the</strong>rs depending on local policies and protocols)<br />
• diagnostics (including blood tests, X-rays, endoscopy, bronchoscopy and<br />
sigmoidoscopy).<br />
This will vary across hospital sites.<br />
In each case above, we are referring to <strong>the</strong> hospital-based aspects <strong>of</strong> care or<br />
diagnosis. We are conscious, <strong>of</strong> course, that a significant amount <strong>of</strong> services in this<br />
area can and should be provided in <strong>the</strong> primary care setting.<br />
Much <strong>of</strong> this type <strong>of</strong> work is still carried out largely in <strong>the</strong> bigger <strong>hospitals</strong>, despite <strong>the</strong><br />
o<strong>the</strong>r pressures facing <strong>the</strong>m. It makes little sense to retain all <strong>of</strong> <strong>the</strong>se services in<br />
bigger <strong>hospitals</strong> when <strong>the</strong>y can safely be carried out in <strong>the</strong> <strong>smaller</strong> facilities.<br />
Transferring even some <strong>of</strong> this work frees <strong>the</strong> larger units to concentrate on <strong>the</strong><br />
treatments that only <strong>the</strong>y can provide. It also brings more services closer to local<br />
communities, since <strong>the</strong>y will not have to travel to <strong>the</strong> larger hospital for <strong>the</strong>m.<br />
We also recognise that some services cannot safely be provided in <strong>smaller</strong> <strong>hospitals</strong>,<br />
and that <strong>the</strong>y need to be moved in a planned way to <strong>the</strong> larger <strong>hospitals</strong> best placed<br />
to provide <strong>the</strong>m. Again however, we will not assume that larger <strong>hospitals</strong> are<br />
automatically safer. They must be properly organised and all <strong>hospitals</strong> will ultimately<br />
be subject to licensing requirements for quality and safety.<br />
- The links with Primary Care<br />
It is vital to link <strong>the</strong> role <strong>of</strong> <strong>smaller</strong> <strong>hospitals</strong> closely with <strong>the</strong> provision <strong>of</strong> primary care.<br />
Smaller <strong>hospitals</strong> can provide accessible health care and ancillary services to meet<br />
<strong>the</strong> needs <strong>of</strong> defined local populations, particularly in remote areas. They should be<br />
seen as a logical extension <strong>of</strong> Primary Care, where <strong>the</strong>y have huge potential to<br />
enable GPs and primary care teams to support patients within <strong>the</strong>ir own community.<br />
Rehabilitation is a major role <strong>of</strong> <strong>smaller</strong> <strong>hospitals</strong>, and <strong>the</strong>y should <strong>of</strong>fer a wide range<br />
<strong>of</strong> health promotion, diagnostic, emergency, acute and convalescent services, as well<br />
as providing premises for consultant out-patient clinics and out-<strong>of</strong>-hours treatment<br />
centres.<br />
4
The influence and involvement <strong>of</strong> primary care and general practice in small <strong>hospitals</strong><br />
will mean a welcome change <strong>of</strong> emphasis towards “small can work”. Flexibility should<br />
be a key feature <strong>of</strong> service planning delivery.<br />
Being small in size should be viewed as providing immense capacity for flexibility and<br />
change, with each hospital evolving in a unique way to meet local needs and closely<br />
linked to primary care teams and health and social care networks. This will enable a<br />
fusing <strong>of</strong> traditional boundaries between primary and secondary care, and <strong>the</strong><br />
establishment <strong>of</strong> an integrated policy for health and social needs.<br />
- European Working Time Directive<br />
One <strong>of</strong> <strong>the</strong> key factors influencing <strong>the</strong> type <strong>of</strong> services that can safely be provided in<br />
individual <strong>hospitals</strong> is <strong>the</strong> availability <strong>of</strong> medical staff. Some services can only be<br />
provided when appropriately trained and experienced medical staff are present. This<br />
has important implications for <strong>the</strong> services that <strong>smaller</strong> <strong>hospitals</strong> can provide,<br />
especially at night time and weekends.<br />
The European Working Time Directive (EWTD) sets down strict limits on <strong>the</strong> average<br />
working hours permitted for NCHDs. This limits <strong>the</strong> scope for more extensive rosters,<br />
especially in <strong>smaller</strong> <strong>hospitals</strong>. Ireland has recently been formally requested by <strong>the</strong><br />
European Commission to detail how it will implement <strong>the</strong> Directive in relation to<br />
NCHDs. While some progress has been made in recent years, <strong>the</strong>re is more to be<br />
done to achieve full compliance. For this reason, <strong>the</strong> EWTD will be one <strong>of</strong> <strong>the</strong> most<br />
significant drivers <strong>of</strong> change in our acute hospital services as a whole.<br />
- Costs and Logistics<br />
It is clear that we are operating within very difficult financial circumstances. The<br />
changes emanating from this Framework will have to be implemented during a time<br />
<strong>of</strong> reduced budgets for health care overall, and in particular a reduction for acute<br />
<strong>hospitals</strong> as we continue <strong>the</strong> shift in emphasis to community-based services including<br />
primary care.<br />
The costs <strong>of</strong> transferring services must be identified in advance, and a decision taken<br />
on how to address <strong>the</strong>se. We will prioritise changes that can be achieved without<br />
extra cost. This may occur, for example, where staff (or staff sessions) are<br />
transferring with a specified volume <strong>of</strong> service, and <strong>the</strong> receiving hospital has <strong>the</strong><br />
capacity to deal with this by a transfer <strong>of</strong> <strong>the</strong> corresponding budget. Our priority will<br />
be to increase <strong>the</strong> number <strong>of</strong> patients treated in <strong>smaller</strong> <strong>hospitals</strong>, but this may be<br />
done in a number <strong>of</strong> ways, including with reduced budgets, for example, by reducing<br />
staff cover at less busy times for elective work such as at nights and weekends.<br />
Where extra costs cannot be avoided, <strong>the</strong>se will be quantified, and an approach to<br />
dealing with <strong>the</strong>m identified, e.g. through savings elsewhere. In any event, we will<br />
adhere to a clear set <strong>of</strong> principles underlying resource issues:<br />
• <strong>the</strong> transfer <strong>of</strong> services will entail a transfer <strong>of</strong> <strong>the</strong> corresponding budget<br />
• <strong>the</strong>re will be agreement on where to apply any savings achieved from <strong>the</strong><br />
reorganisation <strong>of</strong> services between <strong>smaller</strong> and larger <strong>hospitals</strong><br />
• we will pursue <strong>the</strong> use <strong>of</strong> alternative community-based services to help reduce<br />
resource requirements overall.<br />
5
In order to ensure public confidence in <strong>the</strong> proposed changes it will be important that<br />
a number <strong>of</strong> essential arrangements are in place in advance <strong>of</strong> any changes to <strong>the</strong><br />
services. It will also be important that relevant ambulance bypass protocols are<br />
developed and implemented, that <strong>the</strong> capacity <strong>of</strong> <strong>the</strong> larger <strong>hospitals</strong> to take on <strong>the</strong><br />
additional work has been verified, and that issues regarding emergency patient<br />
transport have been addressed.<br />
- The Challenge <strong>of</strong> Change<br />
Changes to <strong>the</strong> way <strong>hospitals</strong> provide services are always difficult and must be<br />
implemented carefully to ensure that <strong>the</strong> result is both safe for patients and efficient<br />
for <strong>the</strong> taxpayer. We will ensure that all changes<br />
• are delivered to secure patient safety, including implementation <strong>of</strong> <strong>the</strong><br />
recommendations <strong>of</strong> HIQA;<br />
• meet <strong>the</strong> needs <strong>of</strong> patients in <strong>the</strong> best way in <strong>the</strong> right location;<br />
• are provided in a way that enables <strong>hospitals</strong> to deliver services within budget;<br />
• are implemented using <strong>the</strong> practices and protocols <strong>of</strong> <strong>the</strong> clinical programmes so<br />
as to facilitate service transfers in both directions (big to small and vice versa)<br />
and<br />
• are implemented with <strong>the</strong> full involvement <strong>of</strong> local communities.<br />
This will need well co-ordinated clinical and management action.<br />
- Consultation<br />
The HSE is now engaging in a consultation process to help inform <strong>the</strong> details <strong>of</strong> <strong>the</strong><br />
service changes. The consultation process will seek to:<br />
• get feedback from all stakeholders, starting with <strong>the</strong> pr<strong>of</strong>essionals in each<br />
hospital who deliver <strong>the</strong> service.<br />
• listen to, and address as much as possible, <strong>the</strong> concerns <strong>of</strong> stakeholders.<br />
There will be a structured process <strong>of</strong> feedback, so that key messages are captured<br />
as an input to <strong>the</strong> change process.<br />
Conclusion<br />
This Framework is <strong>the</strong> first <strong>of</strong> its kind to describe a genuinely positive role for <strong>smaller</strong><br />
<strong>hospitals</strong> in <strong>the</strong> <strong>future</strong>. We have set out as much information as possible based on<br />
<strong>the</strong> plans to date, and we will develop <strong>the</strong>se fur<strong>the</strong>r in <strong>the</strong> months ahead. We do not<br />
have all <strong>of</strong> <strong>the</strong> answers at this stage, nor would we expect to have. None<strong>the</strong>less, we<br />
will continue to consult with local communities, health pr<strong>of</strong>essionals and o<strong>the</strong>r<br />
stakeholders on <strong>the</strong> details as <strong>the</strong> change process develops.<br />
Above all, we will seek to explain what is happening, when and why.<br />
In Part Two we describe <strong>the</strong> type <strong>of</strong> services that can and should be provided in our<br />
<strong>smaller</strong> <strong>hospitals</strong>. This is based closely on <strong>the</strong> work <strong>of</strong> <strong>the</strong> HSE’s Clinical<br />
Programmes. The exact services to be provided in each <strong>smaller</strong> hospital will vary<br />
according to local circumstances, but <strong>the</strong> approach set out in Part Two provides <strong>the</strong><br />
major principles and criteria on which <strong>the</strong> development <strong>of</strong> acute services should be<br />
based. The consultation process will help us finalise <strong>the</strong> exact range and type <strong>of</strong><br />
services that will be provided in each case.<br />
6
Part Two<br />
Services in Smaller Hospitals (Model 2<br />
Hospitals)<br />
7
1. Introduction<br />
Smaller <strong>hospitals</strong> are very well regarded by <strong>the</strong> local population and general<br />
practitioners. More recently, <strong>the</strong>re have been very significant developments in<br />
healthcare delivery particularly in <strong>the</strong> context <strong>of</strong> shifts to day surgery and ambulatory<br />
care and <strong>the</strong> centralisation <strong>of</strong> low volume high complexity care into larger centres. In<br />
this context, it is necessary that we redefine <strong>the</strong> role <strong>of</strong> <strong>the</strong> <strong>smaller</strong> <strong>hospitals</strong> so that<br />
<strong>the</strong>y continue to play a central part <strong>of</strong> <strong>the</strong> <strong>Irish</strong> Healthcare system.<br />
This Framework for Smaller Hospitals defines <strong>the</strong> role <strong>of</strong> <strong>the</strong> <strong>smaller</strong> <strong>hospitals</strong>. It<br />
outlines <strong>the</strong> need for <strong>smaller</strong> <strong>hospitals</strong> and larger <strong>hospitals</strong> to operate as a single<br />
Hospital Group. It defines <strong>the</strong> need for <strong>the</strong> <strong>smaller</strong> hospital to be supported within<br />
<strong>the</strong> Hospital Group in terms <strong>of</strong> education and training, continuous pr<strong>of</strong>essional<br />
development, <strong>the</strong> sustainable recruitment <strong>of</strong> high quality clinical staff and <strong>the</strong> safe<br />
management <strong>of</strong> deteriorating and complex patients. The Framework also outlines in<br />
detail <strong>the</strong> wide range <strong>of</strong> services that can provided within <strong>the</strong> <strong>smaller</strong> hospital and<br />
that can transferred from <strong>the</strong> larger to <strong>smaller</strong> <strong>hospitals</strong> within <strong>the</strong> Hospital Group.<br />
The successful implementation <strong>of</strong> <strong>the</strong> Framework for Smaller Hospitals, within <strong>the</strong><br />
context <strong>of</strong> Hospital Groups, provides <strong>the</strong> opportunity to deliver safe and effective care<br />
at <strong>the</strong> lowest level <strong>of</strong> complexity and closest to <strong>the</strong> patient’s home. It also provides<br />
<strong>the</strong> opportunity for <strong>smaller</strong> <strong>hospitals</strong> to have a sustainable and central role into <strong>the</strong><br />
<strong>future</strong>.<br />
We now identify <strong>the</strong> activities that can be performed in <strong>smaller</strong> <strong>hospitals</strong> in a safe and<br />
sustainable manner so that a high volume <strong>of</strong> care can be provided locally. It will be<br />
necessary to transfer a significant amount <strong>of</strong> this type <strong>of</strong> activity from larger to<br />
<strong>smaller</strong> <strong>hospitals</strong> to ensure patients receive <strong>the</strong>ir treatment locally and to create<br />
capacity in <strong>the</strong> larger <strong>hospitals</strong> to accept <strong>the</strong> <strong>smaller</strong> volume higher complexity care.<br />
It is recognised that appropriate streaming <strong>of</strong> patients into <strong>smaller</strong> and larger<br />
<strong>hospitals</strong> is already in existence and <strong>the</strong>se practices should continue where <strong>the</strong>y are<br />
operating safely and effectively.<br />
2. The organisation <strong>of</strong> hospital services<br />
2.1 The models <strong>of</strong> <strong>hospitals</strong><br />
The acute medicine programme defined <strong>hospitals</strong> as model 1-4 based on <strong>the</strong> type <strong>of</strong><br />
activity that can be provided.<br />
Model 1 <strong>hospitals</strong> are community <strong>hospitals</strong> where patients are currently under <strong>the</strong><br />
care <strong>of</strong> resident medical <strong>of</strong>ficers. These <strong>hospitals</strong> do not have surgery, emergency<br />
care, acute medicine (o<strong>the</strong>r than a select group <strong>of</strong> low risk patients) or critical care.<br />
Model 2 <strong>hospitals</strong> are discussed in detail below. These <strong>hospitals</strong> can provide <strong>the</strong><br />
majority <strong>of</strong> hospital activity including extended day surgery, selected acute medicine,<br />
local injuries, a large range <strong>of</strong> diagnostic services (including endoscopy, laboratory<br />
medicine, point-<strong>of</strong>-care testing, and radiology (CT, US and plain film X Ray))<br />
specialist rehabilitation medicine and palliative care.<br />
Model 3 <strong>hospitals</strong> will provide 24/7 acute surgery, acute medicine, and critical care.<br />
8
Model 4 <strong>hospitals</strong> will be similar to model 3 hospital but will provide tertiary care and,<br />
in certain locations, supra-regional care.<br />
2.2 Overall governance<br />
• All <strong>hospitals</strong> (ranging from model 2 to model 4 <strong>hospitals</strong>) must operate within<br />
single Hospital Groups.<br />
• Smaller <strong>hospitals</strong> provide a unique and essential opportunity for <strong>the</strong><br />
undergraduate and post graduate training <strong>of</strong> all our healthcare pr<strong>of</strong>essionals. To<br />
ensure <strong>the</strong>se benefits are realised, education and training should be organised<br />
on a network basis across <strong>the</strong> Hospital Group. In addition staff working within<br />
<strong>smaller</strong> <strong>hospitals</strong> need to be full participants in network-based continuous<br />
pr<strong>of</strong>essional development programmes.<br />
• Smaller <strong>hospitals</strong> need to be full participants in a comprehensive clinical<br />
governance infrastructure for <strong>the</strong> Hospital Group.<br />
• Doctors (including consultants and junior doctors) should be appointed to single<br />
departments which operate across <strong>the</strong> Hospital Group. Junior doctors should<br />
rotate across <strong>the</strong> Hospital Group as part <strong>of</strong> <strong>the</strong>ir training.<br />
• A single executive structure and function should be implemented across <strong>the</strong><br />
Hospital Group to ensure that <strong>the</strong> <strong>hospitals</strong> operate as effectively and efficiently<br />
as possible. There should be GP representation in <strong>the</strong> governance structures.<br />
3. The Model 2 Hospital<br />
3.1 Characteristics:<br />
The <strong>future</strong> growth in healthcare will be in <strong>the</strong> services such as ambulatory care<br />
(including chronic disease management and day surgery), diagnostics and<br />
rehabilitation which will be based in model 2 <strong>hospitals</strong>. As a result <strong>of</strong> <strong>the</strong>se emerging<br />
models <strong>of</strong> healthcare delivery and <strong>the</strong> ageing population, <strong>the</strong> total volume <strong>of</strong> activity<br />
<strong>of</strong> <strong>the</strong> model 2 <strong>hospitals</strong> will grow substantially. Model 2 <strong>hospitals</strong> will be part <strong>of</strong> a<br />
network <strong>of</strong> <strong>hospitals</strong> operating as single departments such that:<br />
1. linked specialist services to <strong>the</strong>se units will be under <strong>the</strong> governance <strong>of</strong> a<br />
single directorate embracing <strong>the</strong> model 2 Hospital with linked model 3 or<br />
model 4 hospital(s);<br />
2. this single governance will be reflected in <strong>the</strong> appointment <strong>of</strong> Clinical<br />
Directors across <strong>the</strong> Hospital group and make provision for staff to move<br />
between sites, as appropriate; and for care to be provided on two sites <strong>the</strong>re<br />
must be access to <strong>the</strong> full records on each site, including letters, clinical<br />
notes, operating notes, laboratory and o<strong>the</strong>r data.<br />
3.2 Overview <strong>of</strong> services at a Model 2 Hospital<br />
• The hospital will have a daytime Urgent Care Centre comprising a <strong>Medical</strong><br />
Assessment Unit and Local Injuries Unit which will be open where feasible 7 days<br />
a week.<br />
• Subject to local consultation consideration should be given to supporting <strong>the</strong><br />
provision <strong>of</strong> on site GP out <strong>of</strong> hours services as already exists in a number <strong>of</strong><br />
locations.<br />
9
• Pre hospital care needs to be developed with appropriate linkages to primary<br />
care, especially GP out <strong>of</strong> hours services in rural areas. GPs will refer selected<br />
medical patients (i.e. unlikely to require high intensity cardiopulmonary and/or<br />
neurological support) for assessment in <strong>the</strong> MAU during daytime hours.<br />
• Patients will self refer to <strong>the</strong> daytime Local Injury Unit or co-located GP OOH<br />
services .<br />
• The hospital will see and admit medical patients on a 24 hour basis. It will provide<br />
in-patient and out-patient care for low risk differentiated medical patients who are<br />
not likely to require full resuscitation. All patients will have an appropriate care<br />
plan.<br />
• The hospital will provide day surgery and will have <strong>the</strong> capacity to admit some <strong>of</strong><br />
<strong>the</strong>se patients overnight based on pre agreed criteria (as discussed below in<br />
relation to surgery).<br />
• The hospital will be able to provide <strong>the</strong> vast majority <strong>of</strong> outpatient services.<br />
• Patient flow will be enhanced by expanded nursing and <strong>the</strong>rapy practice (e.g.<br />
nurse prescribing <strong>of</strong> medicinal products and ionising radiation/X-rays and <strong>the</strong>rapy<br />
facilitated discharge). These services will be developed in response to service<br />
need.<br />
• All model 2 <strong>hospitals</strong> must have an in-house clinical pharmacy service or formal<br />
access to, and reporting relationship with, <strong>the</strong> service in a model 3 or model 4<br />
hospital.<br />
• The Hospital Group must have a person trained and responsible for infection<br />
prevention and control on site and formal access to advice from a consultant<br />
microbiologist/infectious disease physician.<br />
3.3 <strong>Medical</strong> and Critical Care Services for a Model 2 Hospital<br />
• This hospital will not have an ICU, so <strong>the</strong> patient will be assessed and tracked<br />
using <strong>the</strong> national early warning score and where appropriate, this score will<br />
prompt an acute medicine response and if necessary, transfer to <strong>the</strong> associated<br />
model 3 or model 4 hospital.<br />
• The following applies to anaes<strong>the</strong>sia/ critical care requirements <strong>of</strong> Model 2<br />
Hospitals<br />
o An adequate retrieval service needs to be in place to allow model 2<br />
<strong>hospitals</strong> accept low risk medical inpatients due to <strong>the</strong> potential that <strong>the</strong>se<br />
patients may deteriorate and require urgent critical care and transfer into<br />
<strong>the</strong> associated model 3 or 4 <strong>hospitals</strong><br />
o <strong>Medical</strong> staff who are providing inpatient and walk-in treatment within <strong>the</strong><br />
model 2 hospital need to be Advanced Cardiac Life Support certified and<br />
have completed <strong>the</strong> BASIC (Basic Assessment and Skills in Intensive<br />
Care) course or equivalent.<br />
o <strong>Medical</strong> staff who are training in acute medicine support should ideally<br />
rotate through critical care rotations and such rotations should be<br />
developed and implemented<br />
o<br />
The implementation <strong>of</strong> <strong>the</strong> new roles for model 2 <strong>hospitals</strong> will require a<br />
plan for managing anaes<strong>the</strong>tic/critical care requirements <strong>of</strong> patients in<br />
each location. The redeployment <strong>of</strong> anaes<strong>the</strong>tic staff to cover <strong>the</strong><br />
enhanced critical care activity in <strong>the</strong> model 3 and 4 locations should not<br />
occur until on site medical staff in <strong>the</strong> Model 2 <strong>hospitals</strong> are Advanced<br />
Cardiac Life Support certified and have completed <strong>the</strong> Basic Assessment<br />
and Skills in Intensive Care or equivalent, and that <strong>the</strong> retrieval service to<br />
<strong>the</strong> associated model 3 or 4 hospital is in place.<br />
• A patient’s condition may deteriorate and after treatment, patients with acuity <strong>of</strong><br />
ICS Level 2 unstable or Level 3 (ref appendix 17.9 <strong>of</strong> Acute Medicine Programme<br />
document) will require critical care retrieval and transfer to ICU in a model 3 or<br />
model 4 hospital.<br />
10
• There will be guaranteed acceptance <strong>of</strong> transfer <strong>of</strong> all patients who deteriorate by<br />
<strong>the</strong> associated model 3 or model 4 hospital (bi-directional patient flow must also<br />
occur as required).<br />
• Patients requiring palliative care, respite, rehabilitation and pre-discharge care<br />
and low risk differentiated patients with direct GP to consultant referral (via MAU)<br />
can be admitted to this hospital.<br />
• Patients will be admitted from <strong>the</strong> MAU under <strong>the</strong> care <strong>of</strong> a named consultant,<br />
and out-<strong>of</strong>-hours selected medical patients can be admitted by agreement<br />
between <strong>the</strong> G.P. and <strong>the</strong> on-call medical team/consultant.<br />
• The medical department and medical staff need to be part <strong>of</strong> a wider rotation<br />
under <strong>the</strong> governance <strong>of</strong> <strong>the</strong> acute medicine service in <strong>the</strong> linked model 3 or<br />
model 4 hospital. During <strong>the</strong> day <strong>the</strong>re will be appropriate NCHD presence in <strong>the</strong><br />
MAU and wards.<br />
• The medical staffing at night will be a resident medical registrar/SpR +/- a senior<br />
house <strong>of</strong>ficer (both <strong>of</strong> whom are advanced cardiac life support [ACLS] certified<br />
with formal assessed training in airway management). In addition <strong>the</strong>re will be a<br />
consultant on-call.<br />
• Nurse staffing at night will include a nurse manager/supervisor for <strong>the</strong> nursing<br />
services.<br />
• Therapy staffing will be senior grade to staffing complement managed across<br />
hospital group to ensure appropriate expertise and supervision on model 2 sites.<br />
Clinical specialists in model 3 and model 4 <strong>hospitals</strong> will provide advice and/or<br />
support as required.<br />
• Standards <strong>of</strong> care should be measured and should be comparable to those<br />
delivered in model 3 and model 4 <strong>hospitals</strong>.<br />
• The following day services are appropriate based on local need and capacity:<br />
o Day services/ambulatory care assessment for older persons<br />
o Antenatal care/postnatal care<br />
o Gynaecology Clinics<br />
o Full range <strong>of</strong> Endoscopy (Bronchoscopy, Cystoscopy, Colonoscopy, OGD,<br />
Sigmoidoscopy),<br />
o PEG tube insertion<br />
o Non-invasive cardiology<br />
o Cardiac failure clinic<br />
o Cardiac rehabilitation service<br />
o Venesection, infusion and transfusion <strong>the</strong>rapy<br />
o Bone marrow aspiration and trephine biopsy<br />
o Abdominal paracentesis and thoracentesis<br />
o Lumbar puncture<br />
o Diabetic day centre including foot care and eye care<br />
o Rheumatology day services/Clinics<br />
o Dermatology day services/Clinics<br />
o Oncology/haematology day ward/Clinics<br />
o Mental health day services/Clinics<br />
o COPD outreach/Clinics<br />
o Pulmonary rehabilitation/Clinics<br />
o Hepatology day services/Clinics<br />
o Diagnostic imaging<br />
o Rehabilitation day services/Clinics<br />
o General Rehabilitation medicine<br />
o Pros<strong>the</strong>tic and Orthotic clinic<br />
o O<strong>the</strong>r services, depending on local policies and protocols.<br />
11
• The following additional services apply to Model 2 <strong>hospitals</strong><br />
Specific issues relating to Model 2 hospital services<br />
Acute cardiology Patients should be managed according to referral guidelines and<br />
clinical protocols. An out-patient clinic session should be provided<br />
by a visiting cardiologist one day per week to review <strong>the</strong> results <strong>of</strong><br />
non-invasive tests. Patients with acute presentations should be<br />
transferred to a model 3 or model 4 hospital according to protocol.<br />
Ambulance services Ambulance services will develop protocols for ambulance transfer<br />
to and between <strong>hospitals</strong> in consultation with GP’s and Hospital<br />
staff.<br />
COPD<br />
In-patients will have care up to, and including, non-invasive<br />
ventilation (NIV) where appropriate based on careful patient<br />
selection.<br />
Diagnostic imaging Plain film X-ray, ultrasound and CT-scanning including CT or US<br />
guided procedures. The diagnostic imaging service should provide<br />
at a minimum timely and direct access to GPs for plan film X-ray<br />
and ultrasound. There will be an on-call diagnostic imaging service<br />
with access to 24-hour reporting for specific modalities from <strong>the</strong><br />
model 4 hospital. The on-call diagnostic imaging service on site<br />
will support GP OOH services.<br />
Heart failure<br />
A heart failure service will be established under <strong>the</strong> governance <strong>of</strong><br />
a lead consultant physician. Selected heart failure patients with a<br />
clearly defined care plan who develop decompensated heart<br />
failure may be admitted. There will be a rapid access clinic for<br />
out-patient IV <strong>the</strong>rapy to stabilise patients with deteriorating heart<br />
failure. A full out-patient service for diagnosis and specialist review<br />
will be provided.<br />
Palliative care Patients with palliative care needs may be managed in model 2<br />
<strong>hospitals</strong> with appropriate support from <strong>the</strong> specialist palliative<br />
care services as required. Services provided in model 2 <strong>hospitals</strong><br />
should be sufficiently flexible and integrated with specialist<br />
palliative care services to allow rapid and efficient movement <strong>of</strong><br />
patients from one care setting to ano<strong>the</strong>r depending on <strong>the</strong>ir<br />
clinical needs and personal preferences. Admission criteria,<br />
discharge protocols and interface with specialist palliative care<br />
services will be according to agreed national palliative care<br />
programme protocols. Specialist Palliative Care services may be<br />
developed locally and linked to Model 2 <strong>hospitals</strong>.<br />
Rehabilitation<br />
The Model 2 <strong>hospitals</strong> can function as a regional centre for<br />
specialist rehabilitation. Patients will be treated by a local<br />
specialist rehabilitation team which may be led by consultants in<br />
specialties o<strong>the</strong>r than Rehabilitative Medicine (e.g. neurology /<br />
stroke medicine) and staffed by <strong>the</strong>rapy and nursing teams with<br />
specialist expertise in <strong>the</strong> target condition with support from<br />
specialist rehabilitation medicine services...<br />
Patient goals are typically focused on restoration <strong>of</strong> function /<br />
independence and co-ordinated discharge planning with a view to<br />
continuing rehabilitation in <strong>the</strong> community.<br />
3.4 Emergency Medicine Services<br />
A Local Injury Unit (LIU) will be located in a model 2 Hospital and will aim to provide<br />
unscheduled emergency care for patients with non-life threatening or limbthreatening<br />
injuries, as conveniently as possible, while ensuring patient safety and<br />
equitable standards <strong>of</strong> care within an Emergency Care Network. LIUs will be open to<br />
new patients where feasible 0800 – 20:00 hrs (or 18:00hrs) followed by two-hours <strong>of</strong><br />
ongoing clinical work for <strong>the</strong> completion <strong>of</strong> patient care. Appendix 1 lists <strong>the</strong><br />
conditions which will be seen in a Local Injury Unit and sets out <strong>the</strong> benefits <strong>of</strong> this.<br />
12
General issues relating to Local Injury Units<br />
• A Local Injury Unit will be located in a model 2 hospital and will be part <strong>of</strong> an<br />
emergency care network and linked to a lead Emergency Department within each<br />
network.<br />
• The Local Injury Units will operate under <strong>the</strong> clinical governance <strong>of</strong> <strong>the</strong> Network<br />
Coordinator for Emergency Medicine.<br />
• There will be no Clinical Decision Unit on site.<br />
• Administrative functions will be centralised within <strong>the</strong> network and only direct<br />
patient contact administrative function (i.e. reception) will be based at <strong>the</strong> Local<br />
Injury Unit.<br />
• Telemedicine may contribute to clinical care in <strong>the</strong> Local Injury Unit<br />
• The unit will be open to new patients for limited hours’ access, followed by twohours<br />
<strong>of</strong> ongoing clinical work for <strong>the</strong> completion <strong>of</strong> patient care .<br />
• Patients may self-present or be referred by GPs with non-life-threatening or nonlimb-threatening<br />
injuries.<br />
• Patients whose care needs cannot be met at <strong>the</strong>se units will be transferred<br />
directly to networked Emergency Department.<br />
• Paediatric patients (i.e. aged under 16 years) may attend, according to network<br />
protocols. The Network Co-ordinator in EM and <strong>the</strong> PEM Lead Clinician will<br />
develop protocols and procedures to ensure <strong>the</strong> safe management <strong>of</strong> children<br />
who access care at Local Injury Unit. All clinical staff in units accepting children<br />
will be trained in paediatric life support and in <strong>the</strong> recognition <strong>of</strong> non-accidental<br />
injury. These units will be integrated into regional and national PEM networks.<br />
Interdependencies for Local Injury Units<br />
Specialty<br />
Acute Medicine<br />
Critical Care<br />
Acute Surgery<br />
Diagnostic<br />
Imaging<br />
Primary Care<br />
Interdependency<br />
There will be an MAU on site<br />
There will be no critical care facility on site.<br />
Surgical consultation may be required from time to time and<br />
straight forward surgical <strong>the</strong>rapy, if appropriate, may be<br />
carried out locally. (e.g. drainage <strong>of</strong> a peri-anal abscess)<br />
On-site immediate access to plain X-ray, ultrasound and CT<br />
where feasible 08:00 to 20:00hrs (or plain X-ray until<br />
22:00hrs depending on hours <strong>of</strong> opening), seven days a<br />
week. Reporting <strong>of</strong> images through network.<br />
Potential role for GPs, who wish to do so, to work in Local<br />
Injury Units. In addition <strong>the</strong>re are potential benefits for LIU<br />
to develop in partnership with <strong>the</strong> local General Practice<br />
community.<br />
• A protocol needs to be put in place which will allow for <strong>the</strong> provision <strong>of</strong> basic<br />
medical/nursing assessment and appropriate treatment <strong>of</strong> a patient who attends<br />
<strong>the</strong> hospital out <strong>of</strong> hours. This protocol needs to be developed in conjunction with<br />
GP out <strong>of</strong> hours service.<br />
Workforce issues for Local Injury Units<br />
• Local Injury Units will be under <strong>the</strong> governance <strong>of</strong> Consultants in EM from <strong>the</strong><br />
lead ED in <strong>the</strong> Hospital Group. There will be at minimum two half-day sessions<br />
<strong>of</strong> Consultant presence in any week, provided by one or more Consultants.<br />
13
Network Consultant staffing arrangements will include this commitment to Local<br />
Injury Units.<br />
• NCHDs, primarily middle-grade doctors, will contribute to patient care and a<br />
middle grade doctor will be present on site at all times. <strong>Medical</strong> staff may rotate<br />
to EDs in <strong>the</strong> Group, according to local arrangements.<br />
• The recruitment and clinical supervision medical staff working in Local Injury<br />
Units will come under <strong>the</strong> governance <strong>of</strong> <strong>the</strong> Coordinator for Emergency Medicine<br />
in <strong>the</strong> Hospital Group.<br />
• Teams <strong>of</strong> Advanced Nurse Practitioners (ANP) will provide most <strong>of</strong> <strong>the</strong> clinical<br />
care in <strong>the</strong>se units and will work within <strong>the</strong> network clinical governance<br />
structures. Highly skilled, experienced ANPs will be needed to work in <strong>the</strong>se units<br />
as <strong>the</strong>re will not be a Consultant in Emergency Medicine on-site.<br />
• Nursing staff will provide a supporting role for ANP and medical staff.<br />
• Dedicated administrative staffing for patient reception and registration will be<br />
required for <strong>the</strong> duration <strong>of</strong> hours <strong>of</strong> opening <strong>of</strong> <strong>the</strong> unit, seven days a week.<br />
• There are potential benefits to Local Injury Units being developed in partnership<br />
with <strong>the</strong> local General Practice community. In addition, <strong>the</strong>re is an opportunity for<br />
GPs who wish to do so to work in Local Injury Units. The governance, training<br />
and work practice details will be developed in consultation with <strong>the</strong> relevant<br />
stakeholders.<br />
• Staff will rotate through networked units for education and CPD. CPD and<br />
education will be provided within <strong>the</strong> Emergency Care Network and through e-<br />
learning and o<strong>the</strong>r linked supports. All staff will rotate from <strong>the</strong> Local Injury Unit to<br />
<strong>the</strong> network centre for mandatory training, education and CPD.<br />
Patients whose care needs cannot be met at a Local Injury Unit<br />
• A protocol needs to be implemented to direct <strong>the</strong> initial assessment and transfer<br />
<strong>of</strong> patients whose care needs cannot be met at <strong>the</strong> Local Injury Unit.<br />
• A protocol also needs to be put in place which will allow for <strong>the</strong> provision <strong>of</strong> basic<br />
medical/nursing assessment and appropriate treatment <strong>of</strong> a patient who attends<br />
<strong>the</strong> hospital out-<strong>of</strong>-hours. This protocol should be developed in conjunction with<br />
GP out-<strong>of</strong>-hours services.<br />
3.5 Surgery 1<br />
From a surgical perspective Model 2 Hospitals can be fur<strong>the</strong>r divided into:<br />
• Those that only perform Day Surgery – Model 2D<br />
• Those that perform Stay Surgery (as well as Day Surgery) – Model 2S<br />
• Those that are more than 60 kilometers (Remote/Rural) from <strong>the</strong> nearest<br />
Level 3 or 4 hospital – Model 2R<br />
Surgical services in Model 2D and Model 2R <strong>hospitals</strong><br />
Surgical services and activity planned in Model 2 <strong>hospitals</strong> should take account <strong>of</strong><br />
and complement <strong>the</strong> nature <strong>of</strong> <strong>Medical</strong> services which exist in <strong>the</strong>ir unit. Good<br />
management <strong>of</strong> surgical services demand that:<br />
• The Department <strong>of</strong> Surgery should be managed under <strong>the</strong> governance <strong>of</strong> a<br />
single unit including <strong>the</strong> Model 2 hospital and <strong>the</strong> linked Model 3 or 4<br />
hospital(s).<br />
• This governance structure should be overseen by a single Clinical Director,<br />
with surgical (Consultants, NCHDS, Nursing) and o<strong>the</strong>r staff moving between<br />
sites, as appropriate. It is important for <strong>the</strong> department to be able to<br />
1 Reference from Elective Surgery: Model <strong>of</strong> Care September 2011<br />
14
communicate and work as a single unit. In addition, clinical staff must have<br />
sufficient working time in <strong>the</strong> larger unit so that <strong>the</strong>y don’t deskill in <strong>the</strong><br />
management <strong>of</strong> more complex cases.<br />
• For patient care to be provided on more than one site, a robust mechanism<br />
needs to be planned and delivered such that full patient records, including<br />
letters, clinical notes, operating notes, laboratory and o<strong>the</strong>r data are available<br />
in a timely manner, in order to deliver a safe service9<br />
• Out-patient, pre- and post-operative care and Pre-admission Assessment<br />
should be provided at ei<strong>the</strong>r site for all patients requiring surgery.<br />
• All surgery should be supported by a Pre-operative Assessment Clinic.<br />
• Factors to consider in patient selection are shown in APPENDIX 2 – taken<br />
from <strong>the</strong> Elective Surgery, Model <strong>of</strong> Care. As a general rule, patients for Day<br />
procedures should be expected to make a rapid recovery allowing for speedy<br />
discharge home.<br />
• Surgical procedures that are carried out must only be those appropriate for<br />
Day Surgery. (See APPENDIX 3)<br />
• There should be capacity as well as policies and protocols to provide for<br />
overnight admission <strong>of</strong> an agreed percentage <strong>of</strong> patients (no greater than<br />
20% - this percentage should improve over time as delivery improves).<br />
• There will be no Critical Care back-up or support on site. There will be no out<strong>of</strong>-hours<br />
anaes<strong>the</strong>sia service. Patient assessment and tracking will be<br />
through <strong>the</strong> National Early Warning Scoring System (NEWS) prompting a<br />
defined response and if necessary, transfer to <strong>the</strong> associated model 3 or 4<br />
hospital. Agreed transfer protocols and service will have to be in place to<br />
support <strong>the</strong>se stand alone day surgery units. It is not appropriate that <strong>the</strong><br />
service is hoping to rely on existing personnel and emergency ambulance<br />
service to support <strong>the</strong>ir elective work. The use <strong>of</strong> existing personnel would<br />
mean that <strong>the</strong> elective list would grind to a halt. The use <strong>of</strong> emergency<br />
ambulance services would introduce unacceptable, unquantifiable delays into<br />
<strong>the</strong> service.<br />
• Out <strong>of</strong> hours surgical staffing should include an appropriately qualified senior<br />
nurse (COMPASS certified in NEWS) with cover by medical registrar/SpR<br />
and SHO if required. Given that <strong>the</strong>re will not be any surgery out <strong>of</strong> hours, any<br />
patients who develop serious complications will be transferred, and that those<br />
that remain will have minor issues only. It is not <strong>the</strong>refore necessary to<br />
sustain on site (overnight) surgical trainees except, perhaps, in Model 2R<br />
<strong>hospitals</strong> when <strong>the</strong>y might also cover a minor injuries unit.<br />
• Similarly, a Consultant Surgeon and Anaes<strong>the</strong>tist on call (and free to attend)<br />
would be not be appropriate. Access to a (telephone) opinion from a senior<br />
on-call Surgeon or Anaes<strong>the</strong>tist as needed (Consultant or SpR) at <strong>the</strong> linked<br />
Model 3 or 4 Hospital and <strong>the</strong> facility for early ambulance transfer and<br />
mandatory acceptance when required should be <strong>the</strong> recommended approach.<br />
• There should be access to Endoscopy and o<strong>the</strong>r specialist services as<br />
deemed appropriate.<br />
• Care will be provided for surgical patients requiring palliative, respite,<br />
rehabilitation and pre-discharge care.<br />
• The hospital Minor Injuries Unit will require surgical consultation from time to<br />
time. Patients requiring acute surgery should be transferred to <strong>the</strong> local Model<br />
3 or 4 <strong>hospitals</strong>. Protocols for management <strong>of</strong> minor urgent procedures (for<br />
example, those requiring relatively minor procedures under GA such as<br />
15
suturing or abscess drainage) should be developed and defined at a local<br />
level. It would be hoped that <strong>the</strong>re would be scope to deal with <strong>the</strong>se minor<br />
emergencies on site, ra<strong>the</strong>r than transfer to local Model 3 or 4 unit.<br />
Consideration might be given to <strong>the</strong> reservation <strong>of</strong> an emergency <strong>the</strong>atre slot<br />
on one list on a daily basis.<br />
Specifics Issues Regarding Day Surgery in Model 2D and 2R<br />
Hospitals<br />
Surgical complexity<br />
The complexity <strong>of</strong> surgery that can be carried out in Model 2D and 2R <strong>hospitals</strong> is<br />
limited by <strong>the</strong> lack <strong>of</strong> an Critical Care services, particularly anaes<strong>the</strong>sia, imaging and<br />
diagnostic services. In addition, <strong>the</strong>re is an expectation that all patients should<br />
anticipate a rapid recover and speedy discharge home with easily managed postoperative<br />
pain.<br />
Procedures and patient selection<br />
Suitable Patients for Day Surgery are described in APPENDIX 2. Procedures<br />
appropriate for Day Surgery are outlined in APPENDIX 3.<br />
Overnight stay requirements<br />
The definition <strong>of</strong> a day case patient by <strong>the</strong> HSE on HealthStat is one “who is admitted<br />
to hospital on an elective basis for care and/or treatment which does not require <strong>the</strong><br />
use <strong>of</strong> a hospital bed overnight and who is discharged as scheduled”. It is important<br />
to emphasis <strong>the</strong> distinction between <strong>the</strong> unanticipated admission <strong>of</strong> day surgery<br />
patients (due to relatively minor and predictable "complications" such as nausea,<br />
pain management etc.) and 23-hour surgery patients who require a planned<br />
overnight stay ei<strong>the</strong>r because <strong>the</strong> surgery is <strong>of</strong> greater complexity or <strong>the</strong> patients<br />
level <strong>of</strong> fitness demands it. Providing care for patients who will, by definition, require<br />
an overnight stay falls outside <strong>the</strong> scope <strong>of</strong> Model 2D and 2R <strong>hospitals</strong>.<br />
The deteriorating patient<br />
Complications during <strong>the</strong> early post-operative period after Day Surgery are most<br />
commonly related to pain, post-operative nausea and vomiting (PONV), urinary<br />
retention or bleeding. Pain and PONV should be managed according to protocol.<br />
Urinary retention requires ca<strong>the</strong>terization. Bleeding may be internal or external and<br />
should be managed by first aid measures and recourse to <strong>the</strong> surgical team. Patients<br />
who have procedures with a potential to bleed significantly should not be carried out<br />
in Small Hospitals but <strong>the</strong>re should be facilities for blood to be grouped and held in<br />
<strong>the</strong> nearest blood bank. If blood is not stored on site, consideration has to be taken <strong>of</strong><br />
how long it will take to get to your unit in case <strong>of</strong> emergency. Consideration needs to<br />
be given locally as to <strong>the</strong> desirability <strong>of</strong> always having a supply <strong>of</strong> Group O Negative<br />
on site.<br />
Deterioration may also arise as a result <strong>of</strong> medical problems. During out <strong>of</strong> hours,<br />
surgical patients should be managed an appropriately qualified senior nurse, as<br />
stated in 10 above. It is accepted as part <strong>of</strong> <strong>the</strong> Model 2 protocol, that <strong>the</strong>re should<br />
always be trained ACLS providers on-site. In addition, a locally developed NEWS,<br />
Emergency Response System, as appropriate to <strong>the</strong> hospital model should be in<br />
place with advice from senior on-call clinical decision makers from and transfer to <strong>the</strong><br />
linked Model 3 or 4 Hospital.<br />
16
The Escalation Protocol will include a point at which a decision may be made to<br />
transfer/retrieve <strong>the</strong> patient to a Model 3 or 4 Hospital. This should be protocol driven<br />
with transfer facilitated by <strong>the</strong> regional Critical Care retrieval service.<br />
It is clearly not possible to guarantee that such transfers would be delivered by <strong>the</strong><br />
same personnel involved in delivery <strong>of</strong> <strong>the</strong> day surgery <strong>the</strong>atre list.<br />
Complications occurring after discharge<br />
Support must be provided to patients who are discharged from a Model 2D or 2R<br />
hospital Day Surgery Unit for <strong>the</strong> first 24-hours after surgery. This is in addition to<br />
support available to patients from <strong>the</strong>ir Primary Care services. This should include<br />
<strong>the</strong> issuing <strong>of</strong> contact telephone numbers to patients at <strong>the</strong> time <strong>of</strong> discharge,<br />
including out-<strong>of</strong>-hours. Patients needing urgent assessment or readmission should<br />
be provided with a fast track care plan to <strong>the</strong> hospital and, if necessary,<br />
arrangements made for re-admission, assessment or transfer to a Model 3 or 4<br />
Hospital.<br />
Non-consultant doctor surgical staffing and training<br />
Model 2 <strong>hospitals</strong> will provide useful experience for training purposes (exposure to<br />
day cases, pre- and postoperative clinics, diagnostics etc) as well as requiring o<strong>the</strong>r<br />
service needs such as NEWS. Providing out <strong>of</strong> hours cover to such low acuity sites<br />
with minimal supervision, however, <strong>of</strong>fers poor training value.<br />
Surgical Services in a Model 2S Hospital<br />
The Model 2S Hospital is proposed for use in certain circumstances. These would be<br />
Model 2 Hospitals which work geographically close to and administratively part <strong>of</strong> a<br />
group or network with a Model 3 or 4 <strong>hospitals</strong>. The purpose <strong>of</strong> a Model 2S hospital<br />
would be to provide additional designated capacity for elective surgery for <strong>the</strong> parent<br />
Level 3 or 4 Hospital. A Model 2S hospital would have all <strong>the</strong> features <strong>of</strong> a regular<br />
Model 2 hospital undertaking <strong>the</strong> agreed basket <strong>of</strong> day case procedures. In addition,<br />
it would seek to expand its workload to include more complex elective surgical<br />
procedures in o<strong>the</strong>rwise relatively fit patients. This would be subject to local<br />
agreement between management and clinicians (anaes<strong>the</strong>sia, surgery & nursing) as<br />
to what could be safely delivered within <strong>the</strong> context <strong>of</strong> local staffing, capacity and<br />
peri-operative care.<br />
A Model 2S hospital, from a surgical perspective, is an elective hospital which, as<br />
with all Model 2 <strong>hospitals</strong>, receives no unscheduled, undifferentiated medical or<br />
surgical patients. From a medical perspective <strong>the</strong> service that is delivered should be<br />
identical to that described above for a standard Model 2 hospital except for <strong>the</strong><br />
presence <strong>of</strong> a Surgical Observation Unit which would be exclusively required for<br />
surgical patients.<br />
The concept behind a Model 2 hospital is to provide an elective surgical unit with<br />
designated or protected beds - beds that may be o<strong>the</strong>rwise difficult to rely on in <strong>the</strong><br />
neighbouring Model 3 or 4 <strong>hospitals</strong>. The surgery and anaes<strong>the</strong>sia programmes<br />
support <strong>the</strong> good practice principle that elective surgical services should be<br />
separated from emergency admissions whenever possible. In addition, a physical<br />
separation <strong>of</strong> services may help in dealing with differences in clinical management<br />
that arise between elective and emergency care, as well as facilitating <strong>the</strong> fixed<br />
designation <strong>of</strong> beds. Finally, MRSA-protected elective wards avoid admissions from<br />
<strong>the</strong> emergency department and transfers from within/outside <strong>the</strong> hospital<br />
As well as separating elective from emergency care, elective surgical procedures can<br />
be divided into minor, intermediate and complex. Most minor and intermediate<br />
17
surgery should be performed as day procedures. This activity can and should be<br />
performed in a Model 2S hospital, in <strong>the</strong> same manner as planned for Models 2 and<br />
2R <strong>hospitals</strong>.<br />
Model 2S hospital will have <strong>the</strong> potential to locally decide on <strong>the</strong> feasibility and<br />
capability <strong>of</strong> <strong>the</strong>ir unit to carry out intermediate and complex surgery, which could not<br />
be carried out on a day case basis and would require in-patient stay and<br />
accommodation. These patients would still be worked up as for day care, with a<br />
planned admission on <strong>the</strong> day <strong>of</strong> surgery. (DOSA admissions)<br />
Surgical Services in a Model 2S Hospital:<br />
• The Department <strong>of</strong> Surgery should be managed under <strong>the</strong> governance <strong>of</strong> a<br />
single unit including <strong>the</strong> Model 2 hospital and <strong>the</strong> linked Model 3 or 4<br />
hospital.(s)<br />
• This governance structure should be overseen by a single Clinical Director,<br />
with surgical (Consultants, NCHDS, Nursing) and o<strong>the</strong>r staff moving between<br />
sites, as appropriate. It is important for <strong>the</strong> department to be able to<br />
communicate and work as a single unit. In addition, clinical staff must have<br />
sufficient working time in <strong>the</strong> larger unit so that <strong>the</strong>y don’t deskill in <strong>the</strong><br />
management <strong>of</strong> more complex cases.<br />
• For patient care to be provided on more than one site, a robust mechanism<br />
needs to be planned and delivered such that full patient records, including<br />
letters, clinical notes, operating notes, laboratory and o<strong>the</strong>r data are available<br />
in a timely manner, in order to deliver a safe service9<br />
• Out-patient, pre- and post-operative care and Pre-admission Assessment<br />
should be provided at ei<strong>the</strong>r site for all patients requiring surgery.<br />
• All surgery should be supported by a Pre-operative Assessment Clinic.<br />
• Patient selection issues for day care management are shown in APPENDIX 2.<br />
• Those for same day admission are listed in APPENDIX 4.<br />
• Surgical procedures suitable for day cases management are listed in<br />
APPENDIX 3. Less than ‘5-day care’ surgical procedures could include<br />
intermediate or complex operations carried out by a variety <strong>of</strong> surgical<br />
specialties including General, Gynaecology, Maxill<strong>of</strong>acial, Otolaryngology<br />
Ophthalmic, Plastics, Vascular and Urology. They should be appropriate to<br />
less than 5-day stay surgery in a Model 2S hospital, not anticipating<br />
admission to HDU or ICU post-operatively.<br />
• Local implementation teams should, following multi-disciplinary collaboration,<br />
develop <strong>the</strong> capacity, policies and protocols to manage post-operative<br />
overnight admission on a planned basis, taking into account <strong>the</strong>ir specific<br />
situation and service configuration. All plans should deliver best practice in<br />
relation to patient safety and clinical risk management.<br />
• No patient should have a planned, anticipated need for HDU or ICU care<br />
post-operatively.<br />
• Patients requiring specific fluid management or analgesic requirements (PCA,<br />
Patient controlled Anaes<strong>the</strong>sia or, if decided upon and justified locally, a<br />
nurse provided epidural service) should be managed in a Surgical<br />
Observation Unit (SOU - 3-4 bedded).<br />
• The NEWS “Emergency Response System” will facilitate post-operative<br />
patient assessment and tracking. There should be a defined response to a<br />
critical event (surgical complication/ deterioration in respiratory function,<br />
GSC etc) with early transfer and mandatory acceptance to Critical Care in <strong>the</strong><br />
18
associated model 3 or 4 hospital. This should be protocol driven with transfer<br />
facilitated by <strong>the</strong> regional Critical Care retrieval service<br />
• Out <strong>of</strong> hours staffing should include an appropriately qualified senior nurse<br />
(COMPASS certified in NEWS) and an experienced, resident NCHD (SHO at<br />
>BST 2 or Registrar), surgical or medical or equivalent doctor - provided<br />
he/she is working with appropriately trained nurse in post operative care. In<br />
<strong>the</strong> case <strong>of</strong> non-surgical cover <strong>the</strong>re should be clear protocols for<br />
communication and escalation.<br />
• A senior on-call Surgical or Anaes<strong>the</strong>tic opinion should be available as<br />
needed (Consultant or SpR in last <strong>the</strong>ir 2 years <strong>of</strong> training). This should be<br />
provided by <strong>the</strong> on-call team at <strong>the</strong> neighbouring Model 3 or 4 hospital and<br />
this needs to be protocol driven and managed locally assuring a rapid, safe<br />
and appropriate response. Patients who have a surgical complication out-<strong>of</strong>hours<br />
that cannot be managed on <strong>the</strong> ward <strong>of</strong> <strong>the</strong> Model 2S hospital should<br />
be transferred without delay to <strong>the</strong> neighbouring Model 3 or 4 Hospital<br />
where <strong>the</strong>re should be access to specialist services.<br />
• All patients should have a discharge plan developed from <strong>the</strong> outset <strong>of</strong> <strong>the</strong>ir<br />
surgical journey.<br />
• Care will be provided for surgical patients requiring palliative, respite,<br />
rehabilitation and pre-discharge care. The Hospital Minor Injuries Unit will<br />
require surgical consultation from time to time. Patients requiring acute<br />
surgery should be transferred to <strong>the</strong> local Model 3 or 4 <strong>hospitals</strong>. Protocols for<br />
management <strong>of</strong> minor urgent procedures (for example, those requiring<br />
relatively minor procedures under GA such as suturing or abscess drainage)<br />
should be developed and defined at a local level. It would be hoped that <strong>the</strong>re<br />
would be scope to deal with <strong>the</strong>se minor emergencies on site, ra<strong>the</strong>r than<br />
transfer to local Model 3 or 4 unit. Consideration might be given to <strong>the</strong><br />
reservation <strong>of</strong> an emergency <strong>the</strong>atre slot on one list on a daily basis.<br />
19
4. Developing Smaller Hospitals: Some Practical Examples <strong>of</strong><br />
Service Enhancements<br />
Work is in progress on developing a detailed plan for service enhancements in each<br />
<strong>of</strong> <strong>the</strong> nine <strong>smaller</strong> <strong>hospitals</strong> that are covered by this Framework. These plans are<br />
based on detailed local analysis <strong>of</strong> <strong>the</strong> services in place and what can be provided in<br />
<strong>the</strong> <strong>future</strong>. The projected activity levels will be outlined in detail in each plan.<br />
Mallow General Hospital<br />
As an example, <strong>the</strong> following outlines <strong>the</strong> projected activity changes associated with<br />
<strong>the</strong> implementation <strong>of</strong> this Framework in one exemplar site – that <strong>of</strong> Mallow General<br />
Hospital (MGH).<br />
- Emergency Department Attendances<br />
An audit was conducted on <strong>the</strong> patients currently attending <strong>the</strong> Emergency<br />
Department (ED) at MGH (11,400 patients per year in 2010). When <strong>the</strong> proposed<br />
changes are implemented it is projected that in excess <strong>of</strong> 80% <strong>of</strong> <strong>the</strong> patients<br />
presenting to <strong>the</strong> ED will continue to be seen ei<strong>the</strong>r in <strong>the</strong> Local Injury Unit or in <strong>the</strong><br />
<strong>Medical</strong> Assessment Unit.<br />
- Outpatient Attendances<br />
It is planned to transfer outpatient clinics from <strong>the</strong> larger <strong>hospitals</strong> in Cork city to<br />
MGH. It is projected that <strong>the</strong>re will be a minimum increase in outpatient attendances<br />
<strong>of</strong> 10% (1000 patients) per year at MGH.<br />
- Surgery and endoscopy.<br />
It is projected that emergency surgery (1000 patients per year) and complex surgery<br />
(300 patients per year) will transfer to <strong>the</strong> larger <strong>hospitals</strong> from MGH. Day case<br />
surgery (900) and endoscopies (1000 patients per year) will transfer from <strong>the</strong> Cork<br />
City Hospitals to MGH.<br />
- Acute Medicine<br />
A new medical assessment unit will open with projected activity <strong>of</strong> 1400 patients per<br />
year. In addition, low risk differentiated medical patients will continue to be admitted<br />
to MGH. On <strong>the</strong> basis <strong>of</strong> local analysis, 80% <strong>of</strong> patients will continue to be admitted<br />
(approximately 2000 patients per year).<br />
- Radiology services<br />
The projected activity for radiology investigations is likely to increase and is projected<br />
to be 25,000 cases per year<br />
Overall on <strong>the</strong> basis <strong>of</strong> <strong>the</strong> local analysis, <strong>the</strong> number <strong>of</strong> patients attending as day<br />
case or inpatient admissions at MGH is anticipated to increase from 6,500 cases per<br />
year to 7,400 cases per year after <strong>the</strong> implementation <strong>of</strong> this Framework.<br />
20
Louth County Hospital, Dundalk<br />
There is also an opportunity to learn from <strong>the</strong> experience <strong>of</strong> <strong>smaller</strong> <strong>hospitals</strong> where<br />
<strong>the</strong> pr<strong>of</strong>ile <strong>of</strong> services has already been changed in line with <strong>the</strong> Framework. In<br />
<strong>the</strong>se locations, day case activity has moved from larger to <strong>smaller</strong> <strong>hospitals</strong> and<br />
more complex activity in <strong>the</strong> opposite direction. As a result, high volumes <strong>of</strong> services<br />
are still being delivered locally but <strong>the</strong>y are safe and sustainable.<br />
Louth County Hospital increased its day case activity from 4,249 cases per year in<br />
2006 to 7,116 cases in 2011. This compensated for <strong>the</strong> cessation <strong>of</strong> approximately<br />
4,000 emergency admissions per year leading to an overall reduction in total day<br />
case and inpatient activity from 9,708 to 7,462 patients per year. The closure <strong>of</strong> <strong>the</strong><br />
emergency department was associated with a significant reduction in attendances<br />
and admissions but 50% <strong>of</strong> cases are still successfully managed at <strong>the</strong> Local Injury<br />
Unit where 7,938 patients were treated in 2011.<br />
Louth County Hospital is <strong>the</strong> regional centre for colposcopy services as part <strong>of</strong> <strong>the</strong><br />
cervical cancer screening programme. It has also been designated as a regional<br />
centre for <strong>the</strong> Colorectal Screening Programme and it is projected that this will result<br />
in an additional 2,000 colonoscopies per year when <strong>the</strong> screening programme is fully<br />
operational.<br />
5. The Critical Links with Primary Care<br />
It is well recognised that primary care can safely manage locally <strong>the</strong> majority <strong>of</strong><br />
patients who require only a routine, straightforward level <strong>of</strong> urgent or planned care.<br />
Treatment can be delivered at home or as close to home as possible. The aim <strong>of</strong><br />
developing primary care is to provide up to 90% <strong>of</strong> <strong>the</strong> health and social care in local<br />
communities. This will be achieved through an increase <strong>of</strong> activity in a primary care<br />
setting and <strong>the</strong> redirection <strong>of</strong> health services away from acute <strong>hospitals</strong> to <strong>the</strong><br />
community.<br />
Key to service integration is <strong>the</strong> promotion <strong>of</strong> capacity building in <strong>the</strong> community. This<br />
includes <strong>the</strong> use <strong>of</strong> <strong>smaller</strong> <strong>hospitals</strong> in a local community where appropriate.<br />
Patients in an integrated system are more likely to receive <strong>the</strong> type and quality <strong>of</strong><br />
care <strong>the</strong>y need, when <strong>the</strong>y need it, in <strong>the</strong> most appropriate setting and from <strong>the</strong> most<br />
appropriate health pr<strong>of</strong>essional.<br />
Effective integration <strong>of</strong> care is easier to achieve where primary care team<br />
pr<strong>of</strong>essionals assume key significance in <strong>the</strong> healthcare system through <strong>the</strong>ir role as<br />
gatekeepers to specialist referral.<br />
Out-reach clinics in primary care will be an important means <strong>of</strong> developing more<br />
effective patient care. For example, at least a proportion <strong>of</strong> <strong>the</strong> return visits to out<br />
patient departments are for <strong>the</strong> purpose <strong>of</strong> monitoring , which could be just as<br />
effectively and much more cheaply carried out in primary care. Anti-coagulant<br />
<strong>the</strong>rapy is one example <strong>of</strong> a treatment currently confined to out patient departments<br />
in <strong>Irish</strong> <strong>hospitals</strong> at present but which could be carried out in <strong>the</strong> more appropriate<br />
setting <strong>of</strong> primary care.<br />
21
A number <strong>of</strong> o<strong>the</strong>r areas <strong>of</strong> primary care can benefit both primary care teams and <strong>the</strong><br />
<strong>smaller</strong> <strong>hospitals</strong> working toge<strong>the</strong>r more effectively. These include:<br />
• more structured chronic disease management interactions that are better planned<br />
and managed;<br />
• more opportunities for patient education and self management classes in <strong>the</strong><br />
hospital with shared primary care responsibilities for providing this education<br />
service;<br />
• opportunities for GPs and o<strong>the</strong>r primary care pr<strong>of</strong>essionals to work in <strong>the</strong> Urgent<br />
Care Centres and as part <strong>of</strong> out-reach teams;<br />
• better opportunities for GPs to refer to low complexity day procedures and access<br />
beds for procedures;<br />
• enhanced opportunities for primary care pr<strong>of</strong>essionals to play a role in palliative,<br />
rehab and pre-discharge care;<br />
• IV <strong>the</strong>rapy provision;<br />
• minor Surgery provision;<br />
• nebuliser treatment in <strong>the</strong> case <strong>of</strong> acute asthmatic attack; and<br />
• Specialist <strong>the</strong>rapy Treatment.<br />
In addition, <strong>the</strong> management <strong>of</strong> chronic diseases is a clear example where close cooperation<br />
between primary care and <strong>smaller</strong> <strong>hospitals</strong> can bring very positive results.<br />
Chronic disease forms <strong>the</strong> backbone <strong>of</strong> much workload in general practice, making<br />
<strong>the</strong> extension <strong>of</strong> primary care work into a <strong>smaller</strong> hospital a logical step. Many<br />
patients with a chronic disease do not require <strong>the</strong> high technology <strong>of</strong> higher level<br />
<strong>hospitals</strong> and engagement in <strong>smaller</strong> <strong>hospitals</strong> can promote innovation and<br />
enhanced service delivery more easily than in larger settings with huge benefit both<br />
to patients and <strong>hospitals</strong> alike.<br />
Finally, it is important to acknowledge <strong>the</strong> existing links that already exist between<br />
primary care and <strong>smaller</strong> <strong>hospitals</strong>. We want to cultivate and increase <strong>the</strong>se links to<br />
<strong>the</strong> benefit <strong>of</strong> all patients. The strengths <strong>of</strong> existing arrangements, which we will seek<br />
to develop fur<strong>the</strong>r, include:<br />
• local services: <strong>smaller</strong> <strong>hospitals</strong> provide more convenient services and less costly<br />
access for <strong>the</strong>ir local population. The <strong>the</strong>me <strong>of</strong> patient choice is welcomed and at<br />
<strong>the</strong> heart <strong>of</strong> general practice. direct and timely access to key diagnostic services<br />
• appropriate services: <strong>smaller</strong> <strong>hospitals</strong> will provide a range <strong>of</strong> safe and<br />
appropriate services <strong>of</strong>ten with considerable cost benefits. The range <strong>of</strong> services<br />
can evolve to meet local needs and will not require <strong>the</strong> large capital outlay<br />
essential for many larger <strong>hospitals</strong>;<br />
• modern staffing structures: <strong>smaller</strong> <strong>hospitals</strong> could link with out-<strong>of</strong>–hours primary<br />
care services based in <strong>the</strong>se <strong>hospitals</strong><br />
• improved skill mix: GPs working with <strong>smaller</strong> <strong>hospitals</strong> value <strong>the</strong> close<br />
relationship <strong>the</strong>y can develop with visiting consultants, and may be able to work<br />
alongside those consultants as GPs with special interests. Long before this role<br />
was conceived, most GPs used <strong>the</strong>ir <strong>smaller</strong> <strong>hospitals</strong> to carry out many minor<br />
operations; and-<br />
• extended outpatient services: <strong>the</strong>se can benefit patients as <strong>the</strong>re is <strong>of</strong>ten<br />
easier access at a convenient location (especially for older people), and<br />
peripheral clinics reduce <strong>the</strong> pressure and congestion at <strong>the</strong> larger<br />
<strong>hospitals</strong>. For medical staff, <strong>the</strong> contact and communication is improved<br />
between GP and consultant.<br />
22
Appendix 1: Conditions Suitable and Unsuitable for Care in a<br />
Local Injury Unit<br />
Adult Patients: Conditions Suitable and Unsuitable for Care in a Local Injury Unit<br />
What <strong>the</strong> Local Injury Unit does treat<br />
What <strong>the</strong> Local Injury Unit does not treat<br />
<br />
Suspected broken bones to legs<br />
Χ<br />
Conditions due to “<strong>Medical</strong>” illness e.g.<br />
from knees to toes<br />
fever, seizures, headache.<br />
<br />
Suspected broken bones to arms<br />
Χ<br />
Injuries following a fall from a height or<br />
from collar bone to finger tips<br />
a road traffic accident<br />
<br />
All sprains and strains<br />
Χ<br />
Serious head injury<br />
<br />
Minor facial injuries<br />
Χ<br />
Chest pain<br />
(including oral, dental and nasal<br />
injuries)<br />
Χ<br />
Respiratory conditions<br />
<br />
Minor scalds and burns<br />
Χ<br />
Abdominal pain<br />
<br />
Wounds, bites, cuts, grazes and scalp<br />
Χ<br />
Gynaecological problems<br />
lacerations<br />
Χ<br />
Neck/back pain<br />
<br />
Small abscesses and boils<br />
Χ<br />
Pregnancy related conditions<br />
<br />
Splinters and fish hooks<br />
Χ<br />
Pelvis or hip fractures<br />
<br />
Foreign bodies in eyes/ears/nose<br />
Minor head injury<br />
(fully conscious patients, who did not<br />
experience loss <strong>of</strong> consciousness or<br />
vomit after <strong>the</strong> head injury)<br />
See notes below.<br />
23
Paediatric Patients: Conditions Suitable and Unsuitable for Care in a Local Injury Unit<br />
What <strong>the</strong> Local Injury Unit does treat<br />
What <strong>the</strong> Local Injury Unit does not treat<br />
Any child aged 5 years or older with:<br />
Suspected broken bones to legs<br />
from knees to toes<br />
Χ<br />
Any child <strong>of</strong> any age with a “<strong>Medical</strong>”<br />
Illness e.g. fever, seizures, respiratory<br />
symptoms<br />
<br />
Suspected broken bones to arms<br />
Χ<br />
Any child younger than 5 years<br />
from collar bone to finger tips<br />
Χ<br />
Any child aged 5 years or older with:<br />
<br />
Any sprain or strain<br />
Χ<br />
Non-traumatic limp or non-use <strong>of</strong><br />
<br />
Minor facial injuries<br />
a limb<br />
(including oral, dental and nasal<br />
injuries)<br />
Χ<br />
Injuries following a fall from a<br />
height or a road traffic accident<br />
<br />
Minor scalds and burns<br />
Χ<br />
Serious head injuries<br />
<br />
Wounds, bites, cuts, grazes and scalp<br />
lacerations<br />
Χ<br />
Abdominal pain<br />
<br />
Splinters and fish hooks<br />
Χ<br />
Gynaecological problems<br />
<br />
Foreign bodies in eyes/ears/nose<br />
<br />
Minor head injury<br />
(fully conscious children, who did not<br />
experience loss <strong>of</strong> consciousness or<br />
vomit after <strong>the</strong> head injury)<br />
See notes below.<br />
Notes on Conditions Suitable and Unsuitable for Care in a Local Injury<br />
Unit<br />
1. Patients should be advised to contact <strong>the</strong>ir General Practitioner for advice if <strong>the</strong>y<br />
are uncertain whe<strong>the</strong>r to attend a Local Injury or Emergency Department.<br />
2. These protocols are intended for use in Local Injury Units, linked to Emergency<br />
Departments and operating within <strong>the</strong> governance framework <strong>of</strong> an Emergency<br />
Care Network.<br />
3. The protocols should be supported by network clinical guidelines. Doctors,<br />
Advanced Nurse Practitioners and Nurses working in Local Injury Units should<br />
have direct access to clinical advice from a Consultant in Emergency Medicine<br />
from <strong>the</strong> lead network ED.<br />
24
4. These are not exhaustive lists, but aim to direct patients with single, isolated and<br />
uncomplicated injuries to <strong>the</strong>se units. Audit <strong>of</strong> patient outcomes and monitoring<br />
<strong>of</strong> Local Injury workload will indicate <strong>the</strong> need for review <strong>of</strong> <strong>the</strong>se lists, as part <strong>of</strong><br />
<strong>the</strong> governance function <strong>of</strong> <strong>the</strong> network.<br />
Benefits that can be achieved through <strong>the</strong> implementation <strong>of</strong> Local<br />
Injury Units<br />
For patients:<br />
• Patients will receive <strong>the</strong> same standards <strong>of</strong> injury care across <strong>the</strong> network, due<br />
to shared protocols, staffing and clinical governance arrangements.<br />
• Patients will not have to travel to larger units for injury care.<br />
• Patients will avoid delays that might be experienced in larger EDs.<br />
• Unscheduled, local ED access is assured for patients with injuries that are nonlife-threatening<br />
and non-limb-threatening.<br />
For <strong>the</strong> healthcare system:<br />
• The model secures <strong>future</strong> involvement in <strong>the</strong> provision <strong>of</strong> emergency services<br />
for <strong>smaller</strong> <strong>hospitals</strong>.<br />
• Existing ED infrastructure will continue to be used for <strong>the</strong> benefit <strong>of</strong> patients.<br />
• The units will be open during <strong>the</strong> times when most ED attendances occur.<br />
• Central larger EDs will be protected from <strong>the</strong> increased demand that would be<br />
caused by redirection <strong>of</strong> patients with injury if all services were centralised.<br />
For emergency care staff:<br />
• Staff can continue to engage in a component <strong>of</strong> emergency medicine without<br />
transferring to centralised units due to complete centralisation <strong>of</strong> services.<br />
• Staff will have enhanced access to training and CPD through rotation within<br />
network.<br />
• Trainees in EM and ANP candidates can gain experience in injury care.<br />
For <strong>the</strong> National Ambulance service:<br />
• More acute injury care delivered locally, thus reducing <strong>the</strong> need for patient<br />
transfers.<br />
25
Appendix 2: Suitable patients for surgery in a Model 2<br />
Hospital 2<br />
Selecting patients for day surgery can be facilitated through use <strong>of</strong> protocols.<br />
Suitability for same day discharge is dependent on patient, anaes<strong>the</strong>tic procedural<br />
and social factors.<br />
Patient Factors:<br />
• Age – <strong>the</strong>re is no upper age limit. Patient selection should be based on<br />
physiological status, not age, i.e. <strong>the</strong> patient should be mentally sound,<br />
reasonably independent and active or under appropriate care.(4)<br />
• There is a lower age limit for day surgery admission. The infant / child must be<br />
older than 56 weeks post-conception i.e. 16 weeks in an infant born at term.<br />
• Good exercise tolerance – a patient should be able to climb stairs without having<br />
to stop.<br />
• BMI – Obesity is not an absolute contra- indication for day care. In general,<br />
patients with a BMI >30 should have an assessment by an anaes<strong>the</strong>tist, unless<br />
clearly stated by local protocol for BMIs >30.<br />
• Patients with a BMI >30 should have an assessment by an anaes<strong>the</strong>tist.<br />
• The patient should not have a major pre-existing disability.<br />
• ASA grade – patients should be ASA grade 1 or 2 or selected ASA grade 3.<br />
Patients with conditions NOT suitable for day surgery in a model 2 <strong>hospitals</strong> are<br />
outlined below<br />
Anaes<strong>the</strong>tic Factors:<br />
o Difficult airway – i.e. large goitre / tumour causing deviation or compression <strong>of</strong><br />
airway, restricted neck movement or mouth opening.<br />
o<br />
o<br />
Personal or family history <strong>of</strong> malignant hyperpyrexia.<br />
Previous personal history <strong>of</strong> previous reaction to anaes<strong>the</strong>sia – type <strong>of</strong><br />
reaction should be assessed and flagged with anaes<strong>the</strong>tist.<br />
o Details <strong>of</strong> any unexplained, significant morbidity during or after anaes<strong>the</strong>sia in<br />
<strong>the</strong> patient, a relative should be noted and discussed with anaes<strong>the</strong>tist.<br />
Cardiovascular<br />
o Poorly controlled blood pressure (BP>170/100)<br />
o Congestive cardiac failure<br />
o Unstable angina<br />
o MI within previous 6 months (14)<br />
o Symptomatic valvular heart disease<br />
o Patients who have a pacemaker or automotive implantable cardiac<br />
defibrillator<br />
o Poor exercise tolerance<br />
Respiratory<br />
o Poorly controlled asthma needing oral steroids, frequently or within last 3<br />
months, frequent hospital admission or home oxygen<br />
o Poorly controlled COPD<br />
o Sleep apnoea<br />
Neurological<br />
o Poorly controlled epilepsy<br />
o CVA/TIA within <strong>the</strong> last 1 year<br />
2 Extracted from Model <strong>of</strong> Care for Elective Surgery, National Surgical Programme,<br />
September 2011<br />
26
Endocrine<br />
o Poorly controlled thyroid disease<br />
o Poorly controlled diabetes<br />
Haematological<br />
o Coagulopathies, INR>1.5, Platelets
Appendix 3: Suitable procedures for Model 2D and 2R<br />
Hospitals<br />
It is possible for 75% <strong>of</strong> all elective operations to be carried out as a day case<br />
surgery. The following procedures represent <strong>the</strong> majority <strong>of</strong> <strong>the</strong>se day case surgical<br />
procedures and are suitable for a model 2 hospital subject to appropriate patient<br />
selection.<br />
1. Orchidopexy<br />
2. Circumcision<br />
3. Inguinal Hernia Repair<br />
4. Anal Fissure Dilatation or Excision<br />
5. Haemorrhoidectomy *<br />
6. Laparoscopic Cholecystectomy*<br />
7. Varicose Vein Stripping or Ligation<br />
8. Transurethral Resection <strong>of</strong> Bladder Tumour<br />
9. Excision <strong>of</strong> Dupuytren’s Contracture<br />
10. Carpal Tunnel Decompression<br />
11. Excision <strong>of</strong> Ganglion<br />
12. Arthroscopy<br />
13. Bunion Operations<br />
14. Removal <strong>of</strong> Metal-ware<br />
15. Extraction <strong>of</strong> Cataract with/without Implant<br />
16. Correction <strong>of</strong> Squint<br />
17. Myringotomy<br />
18. Tonsillectomy*<br />
19. Sub Mucous Resection<br />
20. Reduction <strong>of</strong> Nasal Fracture<br />
21. Operation for Bat Ears<br />
22. Dilatation and Curettage/Hysteroscopy<br />
23. Laparoscopy<br />
The British Association <strong>of</strong> Day Surgery (BADS) has produced a wider list <strong>of</strong><br />
procedures which may be suitable for day surgery in 50% <strong>of</strong> cases and <strong>the</strong>se cases<br />
may be suitable for a model 2 hospital subject to appropriate infrastructure, expertise<br />
and protocols (to be determined locally by <strong>the</strong> Clinical Director in conjunction with<br />
clinical staff) and subject to appropriate patient selection (see appendix 3)<br />
1. Laparoscopic hernia repair<br />
2. Thoracoscopic sympa<strong>the</strong>ctomy*<br />
3. Submandibular gland excision<br />
4. Partial thyroidectomy*<br />
5. Superficial parotidectomy<br />
6. Wide excision <strong>of</strong> breast lump with axillary clearance<br />
7. Urethrotomy<br />
8. Bladder neck incision<br />
9. Laser prostatectomy<br />
10. Trans cervical resection <strong>of</strong> endometrium (TCRE)<br />
11. Eyelid surgery<br />
12. Arthroscopic menisectomy<br />
13. Arthroscopic shoulder decompression<br />
14. Subcutaneous mastectomy<br />
15. Rhinoplasty<br />
16. Dentoalveolar surgery<br />
17. Tympanoplasty<br />
28
NOTE:<br />
• This list is not exhaustive. The question, “Is this patient suitable for day<br />
surgery?” should be replaced by: “Is <strong>the</strong>re any justification for admitting this<br />
case as an inpatient?”<br />
• Procedures marked by * will require clear arrangement for management <strong>of</strong><br />
surgical complications out <strong>of</strong> hours including surgical cover on site ei<strong>the</strong>r in<br />
<strong>the</strong> model 2 hospital or an associated hospital within <strong>the</strong> network and within<br />
reasonable travel distance <strong>of</strong> <strong>the</strong> patient.<br />
• While <strong>the</strong> patient selection criteria outlined in Appendix 3 may be helpful for<br />
some <strong>of</strong> <strong>the</strong>se procedures <strong>the</strong>y do not apply universally. Therefore patient<br />
selection for <strong>the</strong>se procedures needs to be determined by <strong>the</strong> Consultant and<br />
Clinical Director<br />
The following procedures are suitable for model 2 <strong>hospitals</strong> and can be carried out in<br />
an endoscopy, outpatient or minor operations unit but should not usually be<br />
performed in Day Theatres.<br />
Endoscopy<br />
Bronchoscopy<br />
Colonoscopy<br />
Cystoscopy<br />
Oesophagogastroduodenoscopy<br />
Sigmoidoscopy<br />
Outpatients<br />
Colposcopy<br />
Hysteroscopy<br />
Local anaes<strong>the</strong>tic minor operations<br />
Sigmoidoscopy<br />
Pain management procedures and nerve blocks<br />
Urodynamic tests<br />
General Practice or Minor operations unit<br />
Minor procedures (including those outlined above under section titled out-patients)<br />
*Please Note: A number <strong>of</strong> above procedures and investigations which in adults<br />
would generally be carried out in a minor operations unit or outpatient department<br />
cannot be performed on children because <strong>of</strong> <strong>the</strong> requirement for sedation or general<br />
anaes<strong>the</strong>tic e.g. oesophagogastroscopy, colonoscopy, suturing <strong>of</strong> lacerations, dental<br />
extractions.<br />
29
APPENDIX 4 - Suitable patients for Stay Surgery in a Model<br />
2S Hospital<br />
Suitability for surgery in Model 2S Hospitals will be decided in <strong>the</strong> Surgical and Pre-<br />
Anaes<strong>the</strong>tic Assessment Clinics. This will be based on patient factors, procedure<br />
factors and social factors on <strong>the</strong> lines as set out below.<br />
Patient Factors:<br />
The following factors cover some issues to be considered in patient selection. It is up<br />
to individual units to develop <strong>the</strong>ir own selection criteria depending on individual local<br />
unit capability:<br />
• Age – <strong>the</strong>re is no upper age limit. Patient selection should be based on<br />
physiological status, not age, i.e. <strong>the</strong> patient should be mentally sound,<br />
reasonably independent and active or under appropriate care. It needs to be<br />
decided at a local level if <strong>the</strong>re are sufficient resources, clinical/nursing, to<br />
deliver a paediatric surgical day service according to patient safety and<br />
clinical risk management.<br />
• Exercise tolerance – should be good, for example, a patient should be able to<br />
climb stairs without having to stop.<br />
• BMI –Patients with a BMI ≥30 would benefit from pre-operative assessment.<br />
• ASA grade –ASA grade 1, 2 and some ASA grade 3 are suitable. It will be up to<br />
individual units to decide locally, what’s suitable for <strong>the</strong>ir unit.<br />
If medical co-morbidities exist, <strong>the</strong>se should be well controlled. Some examples<br />
include: diabetes - Hb1AC
Securing <strong>the</strong> Future <strong>of</strong> Smaller Hospitals:<br />
A Framework for Development<br />
Published February, 2013